nchcr 20-03 notice of proposed regulations...informative digest/policy statement overview: the cdcr...

CDCR 7554 (07/19)

Department of Corrections and Rehabilitation

NOTICE OF CHANGE TO

HEALTH CARE REGULATIONS

Section(s): 3341.3, 3341.5, 3377.1, 3999.98, 3999.99, 3999.364, 3999.365, and 3999.367.

Number: 20-03

Publication Date: October 2, 2020

Effective Date: TBD

INSTITUTION POSTING AND CERTIFICATION REQUIRED

This Notice announces the proposed amendments to sections 3341.3, 3341.5, 3377.1, 3999.98, 3999.99, 3999.364, 3999.365, and 3999.367 of the California Code of Regulations (CCR), Title 15, Crime Prevention and Corrections, to incorporate into the CCR, provisions concerning health care definitions.

IMPLEMENTATION: To Be Announced

PUBLIC COMMENT PERIOD Any person may submit written comments about the proposed regulations to California Correctional Health Care Services, Health Care Regulations and Policy Section, P.O. Box 588500, Elk Grove, CA 95758, or by email to [email protected]. All written comments must be received by the close of the public comment period, November 23, 2020, at 5:00 p.m.

PUBLIC HEARING INFORMATION Based on guidance from the California Department of Public Health to cancel large community events in order to slow the spread of COVID-19, CDCR will not hold a public hearing on this proposed regulatory action. Written comments submitted during the public comment period, referenced above, are given the same consideration as oral comments presented at a public hearing.

POSTING This Notice shall be posted immediately upon receipt at locations accessible to inmates, parolees, and employees in each Department facility and field office not later than five calendar days after receipt. Also, facilities shall make this Notice available for review by inmates in segregated housing who do not have access to the posted copies and shall distribute it to inmate law libraries and advisory councils. CDCR 621-HC (Rev. 07/20), Certification of Posting, shall be returned to the Health Care Regulations and Policy Section electronically. See Health Care Department Operations Manual, Section 5.1.1 for posting procedures.

CONTACT PERSON Inquiries regarding this action may be directed to D. Gouldy, Associate Director, Risk Management Branch, California Correctional Health Care Services (CCHCS) at California Correctional Health Care Services, P.O. Box 588500, Elk Grove, CA 95758; by telephone at (916) 691-2921; or by email at [email protected]. In the event the contact person is unavailable, inquiries should be directed to A. Burrell, Staff Services Manager II (A), Health Care Regulations and Policy Section, CCHCS at (916) 691-2922.

RALPH DIAZ Secretary California Department of Corrections and Rehabilitation

J. CLARK KELSO Receiver

Attachments

mailto:[email protected]


Notice of Proposed Regulations NCHCR 20-03 Health Care Definitions

September 17, 2020 1

NOTICE OF PROPOSED REGULATORY ACTION

California Code of Regulations Title 15, Crime Prevention and Corrections

Department of Corrections and Rehabilitation NOTICE IS HEREBY GIVEN that the Secretary of the California Department of Corrections and Rehabilitation (CDCR), pursuant to the authority granted by Government Code (GC) section 12838.5 and Penal Code (PC) section 5055, and the rulemaking authority granted by PC section 5058, proposes to amend sections 3341.3, 3341.5, 3377.1, 3999.98, 3999.99, 3999.364, 3999.365, and 3999.367 of the California Code of Regulations (CCR), Title 15, Division 3, concerning health care definitions.

PUBLIC HEARING: Based on guidance from the California Department of Public Health to cancel large community events in order to slow the spread of COVID-19, CDCR will not hold a public hearing on this proposed regulatory action. However, the Department will hold a virtual hearing if it receives a written request for a public hearing from any interested person, or his or her authorized representative, no later than 15 days before the close of the written comment period. Written comments submitted during the public comment period, referenced below, are given the same consideration as oral comments presented at a public hearing. PUBLIC COMMENT PERIOD: The public comment period will close November 23, 2020, at 5:00 p.m. Any person may submit public comments in writing (by mail or by email) regarding the proposed changes. To be considered, comments must be submitted to California Correctional Health Care Services (CCHCS), Health Care Regulations and Policy Section, P.O. Box 588500, Elk Grove, CA, 95758, or by email to [email protected] before the close of the comment period. CONTACT PERSON: Please direct any inquiries regarding this action to: D. Gouldy Associate Director Risk Management Branch California Correctional Health Care Services P.O. Box 588500 Elk Grove, CA 95758 (916) 691-2921

A. Burrell Staff Service Manager II (A) Health Care Regulations and Policy Section

California Correctional Health Care Services (916) 691-2922


2 Notice of Proposed Regulations September 17, 2020 NCHCR 20-03 Health Care Definitions

AUTHORITY AND REFERENCE: GC section 12838.5 provides that commencing July 1, 2005, CDCR succeeds to, and is vested with, all the powers, functions, duties, responsibilities, obligations, liabilities, and jurisdiction of abolished predecessor entities, such as: Department of Corrections, Department of the Youth Authority, and Board of Corrections. PC section 5000 provides that commencing July 1, 2005, any reference to the Department of Corrections in this or any code, refers to the CDCR, Division of Adult Operations.

PC section 5050 provides that commencing July 1, 2005, any reference to the Director of Corrections, in this or any other code, refers to the Secretary of the CDCR. As of that date, the office of the Director of Corrections is abolished. PC section 5054 provides that commencing July 1, 2005, the supervision, management, and control of the state prisons, and the responsibility for the care, custody, treatment, training, discipline, and employment of persons confined therein are vested in the Secretary of the CDCR. PC section 5058 authorizes the Director to prescribe and amend regulations for the administration of prisons. References cited pursuant to this regulatory action are as follows: Sections 3424 and 5054 PC; Sections 3200-3212, Probate Code; Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California; and Perez, et al. v. Cate, et al., (No. C05-05241 JSW), U.S. District Court, Northern District of California. INFORMATIVE DIGEST/POLICY STATEMENT OVERVIEW: The CDCR and CCHCS propose to amend sections 3341.3, 3341.5, 3377.1, 3999.98, 3999.99, 3999.364, 3999.365, and 3999.367 of the CCR, Title 15, Division 3, governing health care definitions. Current law provides for health care definitions and forms pertaining to the treatment of CDCR patients. In January 2019, the Department revised the definition of the term “medically necessary” in Title 15, section 3999.98, establishing this term as the interdisciplinary standard for the provision of health care services. Regulations currently using the term “clinically necessary” must be updated to the term “medically necessary” to conform to current usage as this term now functions as the single interdisciplinary standard for the provision of health care services to CDCR patients. This action provides the following:

• Provide a consistent treatment standard for the delivery of health care services within CDCR institutions.

• Reorganize and integrate various definitions for clarity of reference for patients and staff.

BENEFITS ANTICIPATED BY THE PROPOSED REGULATIONS: The Department anticipates the action will benefit public and patient safety by reorganizing, amending, or relocating definitions, and by clarifying language which will avoid confusion and


prevent inconsistencies in the regulations used in the delivery and governance of medical care within CDCR institutions. FORMS INCORPORATED BY REFERENCE: Not applicable. EVALUATION OF CONSISTENCY/COMPATIBILITY WITH EXISTING REGULATIONS: Pursuant to GC section 11346.5(a)(3)(D), the Department must evaluate whether the proposed regulations are inconsistent or incompatible with existing state regulations. Pursuant to this evaluation, the Department has determined these proposed regulations are not inconsistent or incompatible with any existing regulations within CCR, Title 15, Division 3. LOCAL MANDATES: The proposed regulatory action imposes no mandates on local agencies or school districts, or a mandate which requires reimbursement pursuant to GC section 17500 — 17630.

FISCAL IMPACT STATEMENT: • Cost or savings to any state agency: None • Cost to any local agency or school district that is required to be reimbursed: None • Other nondiscretionary cost or savings imposed on local agencies: None • Cost or savings in federal funding to the state: None EFFECT ON HOUSING COSTS: The Department has made an initial determination that the proposed action will have no significant effect on housing costs because the proposed regulations reorganize, amend, and clarify definitions and language which only affects CDCR patients. SIGNIFICANT STATEWIDE ADVERSE ECONOMIC IMPACT ON BUSINESS: The Department has determined that the proposed action will not have a significant statewide adverse economic impact directly affecting businesses, including the ability of California businesses to compete with businesses in other states because the proposed amendments only reorganize, amend, and clarify definitions and language which only affects CDCR patients. RESULTS OF ECONOMIC IMPACT ASSESSMENT: The Department has determined that the proposed regulations will have no impact on the creation of new or the elimination of existing jobs or businesses within California or affect the expansion of businesses currently doing business in California because the proposed amendments only reorganize, amend, and clarify definitions and language which only affects CDCR patients.


BENEFITS ANTICIPATED BY THE PROPOSED REGULATIONS: The Department anticipates the action will benefit public and patient safety by reorganizing, amending, or relocating definitions, and by clarifying language which will avoid confusion and prevent inconsistencies in the regulations used in the delivery and governance of medical care within CDCR institutions. COST IMPACTS ON REPRESENTATIVE PRIVATE PERSONS OR BUSINESSES: The Department is not aware of any cost impacts that a representative private person or business would necessarily incur in reasonable compliance with the proposed action. The proposed amendments only reorganize, amend, and clarify definitions and language which only affects CDCR patients. EFFECT ON SMALL BUSINESSES: The Department has determined that the proposed regulations will have no significant adverse economic impact on small businesses because the proposed amendments only reorganize, amend, and clarify definitions and language which only affects CDCR patients.

CONSIDERATION OF ALTERNATIVES: The Department must determine that no reasonable alternative it considered or that has otherwise been identified and brought to its attention would be more effective in carrying out the purpose for which the action is proposed, would be as effective and less burdensome to affected private persons than the proposed action, or would be more cost-effective to affected private persons and equally effective in implementing the statutory policy or other provisions of law. The Department has made an initial determination that the action will not have a significant adverse economic impact on business. Additionally, there has been no testimony, reasonable alternative, or other evidence provided that would alter the CDCR’s initial determination to proceed with this action. AVAILABILITY OF PROPOSED TEXT AND INITIAL STATEMENT OF REASONS: The Department has prepared, and will make available, the proposed text and the Initial Statement of Reasons (ISOR) of the proposed regulatory action. The rulemaking file for this regulatory action, which contains those items and all information on which the proposal is based (i.e., rulemaking file) is available to the public upon request directed to the contact person listed in this Notice. The proposed text, ISOR, and Notice of Proposed Action will also be made available on CCHCS’s website https://cchcs.ca.gov and CDCR institution law libraries. AVAILABILITY OF THE FINAL STATEMENT OF REASONS: Following its preparation, a copy of the Final Statement of Reasons may be obtained from the contact person listed in this Notice.

https://cchcs.ca.gov/


AVAILABILITY OF CHANGES TO PROPOSED TEXT: After considering all timely and relevant comments received, the Department may adopt the proposed regulations substantially as described in this Notice. If the Department makes modifications which are sufficiently related to the originally proposed text, it will make the modified text (with the changes clearly indicated) available to the public for at least 15 calendar days before the Department adopts the regulations as revised. Requests for copies of any modified regulation text should be directed to the contact person listed in this Notice. The Department will accept written comments on the modified regulations for 15 calendar days after the date on which they are made available.

Text of Proposed Regulations NCHCR 20-03 April 14, 2020 1

TEXT OF AMENDED REGULATIONS In the following, strikethrough indicates deleted text and underline indicates added text. California Code of Regulations, Title 15, Division 3, Adult Institutions, Programs and Parole Chapter 1. Rules and Regulations of Adult Operations and Programs Subchapter 4. General Institution Regulations Article 7. Segregated Housing

Section 3341.3 is amended to read: Section 3341.3. Security Housing Unit. Introductory text and sections (a) through (c)(3)(A)2. remain unchanged. (d) SHU terms shall be served in a departmentally approved SHU, or a facility specifically designated for that purpose, except under those circumstances where the term may be served in ASU or PSU. SHU terms may also be served in secure inpatient medical or mental health settings, when deemed clinicallymedically necessary. Inmates who are serving a SHU term in ASU shall be reviewed by a classification committee pursuant to section 3341.8. Section (e) remains unchanged. NOTE: Authority cited: Section 5058, Penal Code. Reference: Sections 2933.6, 5054 and 5068, Penal Code; Sandin v. Connor (1995) 515 U.S. 472; Madrid v. Gomez (N.D. Cal. 1995) 889 F.Supp. 1146; Toussaint v. McCarthy (9th Cir. 1990) 926 F.2d 800; Toussaint v. Yockey (9th Cir. 1984) 722 F.2d 1490; and Castillo v. Alameida, et al., (N.D. Cal., No. C94-2847).

Section 3341.5 is amended to read: Section 3341.5. Suspending Security Housing Unit Terms. (a) Determinate SHU Terms. (1) ICC may commute or suspend any portion of a Determinate SHU term. Once commuted, the term shall not be re-imposed. ICC may suspend a Determinate SHU term any time it is determined an inmate no longer poses a threat to the safety of any person or the security of the institution. Additionally, ICC may suspend a Determinate SHU term for purposes of inpatient medical or mental health treatment when deemed clinicallymedically necessary. Any ICC action to suspend or commute a Determinate SHU term shall clearly articulate substantive justification for the decision on the CDC Form 128-G (Rev. 10/89) Classification Chrono. Sections (a)(1)(A) through (a)(3) remain unchanged. (b) Administrative SHU terms.


(1) ICC may end an Administrative SHU term for purposes of inpatient medical or mental health treatment when deemed clinicallymedically necessary. Sections (b)(2) through (b)(4) remain unchanged. NOTE: Authority cited: Section 5058, Penal Code. Reference: Sections 2933.6, 5054 and 5068, Penal Code; Sandin v. Connor (1995) 515 U.S. 472; Madrid v. Gomez (N.D. Cal. 1995) 889 F.Supp. 1146; Toussaint v. McCarthy (9th Cir. 1990) 926 F.2d 800; and Coleman v. Wilson 912 F. Supp. 1282 (E.D. Cal. 1995).

Article 10. Classification Sections 3377.1 is amended to read: Section 3377.1. Inmate Custody Designations. Sections (a) through (c) remain unchanged. (d) A “D” suffix may be affixed by an Institutional Classification Committee (ICC) to a male inmate's Close Custody designation to indicate the inmate may be housed within a dormitory environment. A mental health clinician or physician shall be present during the ICC classification hearing for placement or removal of a D Suffix to an inmate-patient's custody designation. (1) A “D” suffix shall only be affixed by ICC if the inmate meets one of the following criteria and the ICC determines the inmate can safely program in dormitory housing based on a review of the inmate's case factors: (A) Inpatient mental health treatment is deemed clinicallymedically necessary and health care staff have determined that required care cannot be provided in a celled environment. (B) Placement in a specialized medical bed has been deemed clinicallymedically necessary and the Health Care Placement Oversight Program staff have determined the required care cannot be provided in a celled environment. Sections (d)(2) through (d)(3)(B) remain unchanged. NOTE: Authority cited: Section 5058, Penal Code, Reference: Sections 290, 4852.01, 5054 and 5068, Penal Code; Americans With Disability Act (ADA), 42 U.S.C. § 12131, et seq.; and Pennsylvania Department of Corrections v. Yeskey (1998) 524 U.S. 206.

Chapter 2. Rules and Regulations of Health Care Services Article 1. Health Care Definitions Section 3999.98 is amended to incorporate in alphabetical order the following definition; all other definitions within this section are to remain unchanged: 3999.98. Definitions.


Health Record(s) means paper-based records, electronic records, and other media that document the patient's health care and provide a chronological account of a patient's examinations and treatments. Medically Necessary means health care services that are determined by the attending or primary medical, mental health, or dental care provider(s) to be needed to protect life, prevent significant illness or disability, or alleviate severe pain, and are supported by health outcome data or clinical evidence as being an effective health care service for the purpose intended or in the absence of available health outcome data is judged to be necessary and is supported by diagnostic information or specialty consultation. This standard does not confer any additional rights or benefits not currently covered under Medicare.

Article 2. Health Care Forms Section 3999.99 is amended to read: 3999.99. Forms. CDCR 602 HC (Rev. 7/18), Health Care Grievance CDCR 602 HC A (Rev. 12/17), Health Care Grievance Attachment CDCR 7362 (Rev. 03/19), Health Care Services Request Form CDCR 1824 (Rev. 09/17), Reasonable Accommodation Request (Rev. 09/17) CDCR 7225 (Rev. 03/19), Refusal of Examination and/or Treatment (Rev. 03/19) CDCR 7362 (Rev. 03/19), Health Care Services Request Form CDCR 7421 (Rev. 06/18), Advance Directive for Health Care (Rev. 06/18) CDCR 7465 (Rev. 08/16), Physician Orders for Life-Sustaining Treatment (Rev. 08/16) CDCR 7536 (Rev. 05/17), Durable Medical Equipment and Medical Supply Receipt (Rev. 05/17) CDCR 7551 (01/16), Administration or Declination of Coccidioidomycosis Screening (01/16) CDCR MH-7363 (Rev. 01/15), Involuntary Medication Notice CDCR MH-7363-B (01/15), Involuntary Medication Notice: ADD-A-PAGE (01/15) CDCR MH-7366 (Rev. 01/15), Inmate Rights Notice -Involuntary Medication CDCR MH-7368 (01/15), Renewal of Involuntary Medication Notice CDCR MH-7368-B (01/15), Renewal of Involuntary Medication Notice: ADD-A-PAGE (01/15) CDCR MH-7369 (01/15), Penal Code Section 2602 Reconsideration NOTE: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code.

Subchapter 3. Health Care Operations Article 6. Dental Care Section 3999.364 is amended to delete some definitions and incorporate in alphabetical order the following terms formerly included in section 3999.367. 3999.364. Dental Definitions. For the purposes of this Article, the following definitions apply:


Clinically Necessary means health care services or supplies that are determined by health care staff to be needed to diagnose or treat an illness, injury, condition, disease, or its symptoms. Health Record(s) means paper-based records, electronic records, and other media that document the patient's health care and provide a chronological account of a patient's examinations and treatments. Health care records shall be maintained in a manner that supports continuity of care. Patient means an inmate who is seeking or receiving health care services or who is assigned to a care team. Dental Priority Classification means a numerical or alphanumerical code associated with a dental diagnosis and assigned by a dentist. It is the objective expression of the degree of urgency of a patient's dental needs, providing the timeframe within which treatment must be initiated subsequent to the date of diagnosis. Face-to-Face Triage Encounter means a planned visit to assess and diagnose a patient's chief complaint and to provide necessary treatment following submittal of a CDCR 7362, Health Care Services Request Form, by a patient or when dental staff issues a ducat to a patient after performing a health record review. Limited Problem Focused Exam Encounter means an unplanned visit to assess and diagnose a patient's chief complaint and to provide treatment if necessary for a patient with a dental emergency who arrives at the dental clinic unannounced without an appointment or who is referred to the dental clinic by health care or custody staff and dental staff has not issued a ducat to the patient and there is also no record of recently receiving a CDCR 7362 from the patient addressing the emergent condition. Plaque Index Score means a measurement used to determine a patient's level of oral hygiene. Root Canal Therapy means a dental procedure in which the pulp chamber and canal(s) of a tooth are cleaned, shaped and filled.

Section 3999.365 is amended to read: 3999.365. Dental Authorization Review Committee. (a) Each institution shall maintain a Dental Authorization Review (DAR) Committee. The DAR Committee shall approve or disapprove requests for: (1) Dental services otherwiseOtherwise excluded dental services pursuant to section 3999.200(b). (2) Deviations from treatment policy. (3) ClinicallyMedically necessary treatment, as determined by health care staff, that requires a contracted specialist to provide treatment at the local institution. (4) ClinicallyMedically necessary treatments, diagnostic studies, or consultations, as determined by health care staff, that cannot be accomplished at the local institution. (5) Treatment recommendations for special dental care needs. (b) DAR Committee requests at the institution level shall be reviewed and either approved or disapproved within 15 business days of receipt by the DAR Committee and shall be based on criteria established in section 3999.200(c). DAR Committee decisions shall be documented in the patient's health record. Cases that receive DAR Committee approval and that require Dental Program Health Care Review Committee (DPHCRC) approval pursuant to section 3999.366(a), shall be forwarded, along with all supporting documentation, to the DPHCRC. The treating dentist shall notify the patient of the DAR Committee's decision.


(c) The DAR Committee and/or DPHCRC approval process may be bypassed if the Supervising Dentist determines that the specialty services or consultation are required because of an Emergency dental condition, as defined in section 3355.1 3999.367(gf)(1), or an Urgent dental condition requiring that treatment be initiated within one calendar day, as defined in section 3355.13999.367(gf)(2).

Section 3999.367 is amended to read: 3999.367. Dental Care. (a) For the purposes of this section, the definitions pursuant to sections 3352.2(a)(1)-(5) and the following definitions apply: (1) Dental Priority Classification means a numerical or alphanumerical code associated with a dental diagnosis and assigned by a dentist. It is the objective expression of the degree of urgency of a patient's dental needs, providing the timeframe within which treatment must be initiated subsequent to the date of diagnosis. (2) Face-to-face triage encounter means a planned visit to assess and diagnose a patient's chief complaint and to provide necessary treatment following submittal of a CDCR 7362, Health Care Services Request Form, by a patient or when dental staff issues a ducat to a patient after performing a health record review. (3) Limited problem focused exam encounter means an unplanned visit to assess and diagnose a patient's chief complaint and to provide treatment if necessary for a patient with a dental emergency who arrives at the dental clinic unannounced without an appointment or who is referred to the dental clinic by health care or custody staff and dental staff has not issued a ducat to the patient and there is also no record of recently receiving a CDCR 7362 from the patient addressing the emergent condition. (4) Mainline facility means a CDCR facility where a patient is housed and assigned after completing the reception center initial intake process. (5) Plaque index score means a measurement used to determine a patient's level of oral hygiene. (6) Root canal therapy means a dental procedure in which the pulp chamber and canal(s) of a tooth are cleaned, shaped and filled. (ba) Access to Dental Care. (1) Patients shall have equal access to dental services by: (A) Submitting a CDCR 7362, Health Care Services Request Form, requesting dental care for which ducated face-to-face triage encounters shall be scheduled to have specific complaints addressed. (B) Unscheduled dental encounters for emergency and urgent dental services. (C) Referral from other health care providers, ancillary, and custodial staff. (D) Receiving a Dental Priority Classification (DPC) based on clinical findings and radiographs. (2) During a facility lockdown or modified program, dental staff shall coordinate with the clinic Registered Nurse, patient appointment schedulers, and custody staff to facilitate continuity of care. (A) A lockdown or modified program shall not prevent the completion of scheduled dental encounters, and custody personnel shall escort the patient to the dental clinic, subject to security concerns. (B) In facilities or housing units on modified program or lockdown status, a system shall be maintained to provide patients access to health care services.


(3) If a patient's scheduled appointment for Urgent Care, as defined in subsection (gf)(2)(A), is cancelled or rescheduled by dental staff or if a patient unintentionally fails a dental appointment for Urgent Care as defined in subsection (gf)(2)(A), the dentist shall see the patient within one calendar day. For all other dental care needs, the dentist shall see the patient within 35 calendar days of the cancelled appointment or unintentional failure, or consistent with the timeframe associated with the original DPC assigned at the date of diagnosis, whichever is shorter. (4) If a patient's appointment for a face-to-face triage or limited problem focused exam encounter is cancelled or rescheduled by the dental clinic, or if a patient unintentionally fails a face-to-face triage or limited problem focused exam encounter, then the patient shall be seen by a dentist for a face-to-face triage or limited problem focused exam encounter within three business days. (cb) Continuity of Care. Patients shall be provided ongoing dental care in accordance with their DPC as described in subsection (gf). Dentists shall review internal consultation reports, medical and oral pathology lab reports, and reports from outside the facility that are the outcome of a Department or contracted dentist ordering the analysis within seven business days of receipt of the report(s) from the dental clinic and inform patients of the result(s) within three business days of reviewing the report(s). (dc) The Department shall operate in accordance with the California Dental Practice Act, division 2, chapter 4 of the Business and Professions Code (commencing with section 1600), and ensure that all patient protection provisions of the Act are in force. (ed) Dental Program Organizational Structure. The dental program shall maintain a regional administrative structure organized into four regions which shall include a Regional Dental Director and program compliance staff consisting of clinical and non-clinical reviewers. Each Regionregion shall monitor quality of care and dental program policy compliance at the institutions. (fe) Examination and treatment rooms for dental care shall be large enough to accommodate the equipment and fixtures needed to deliver adequate dental services. (gf) Dental Priority Classification. Patients shall be assigned a DPC at the Reception Center Screening, at the time of their comprehensive dental examination at a Mainline Facility their endorsed institution, and after each face-to-face triage, limited problem focused exam, or treatment encounter. This DPC shall be reviewed and appropriately modified after each dental encounter. Patients shall be provided equal access to dental services based upon the occurrence of disease, significant malfunction, or injury and clinicalmedical necessity in accordance with the degree of urgency of a patient's dental needs. (1) Emergency Care. Any dental condition for which evaluation and treatment are immediately necessary, as determined by health care staff, to prevent death, severe or permanent disability, or to alleviate or lessen disabling pain. Emergency dental treatment shall be available on a 24 hour, seven day per week basis. Patients are eligible for Emergency Care regardless of time remaining on their sentence and regardless of their plaque index score. (2) Urgent Care. (A) Patients with a dental condition of sudden onset or in severe pain which prevents the patient from carrying out essential activities of daily living. Treatment shall be initiated within one calendar day from the date of diagnosis. (B) Patients requiring treatment for a sub-acute hard or soft tissue condition that is likely to become acute without early intervention. Treatment shall be initiated within 30 calendar days from the date of diagnosis.


(C) Patients requiring early treatment for any unusual hard or soft tissue pathology. Treatment shall be initiated within 60 calendar days from the date of diagnosis. (D) Patients are eligible for Urgent Care regardless of time remaining on their sentence and regardless of their plaque index score. (3) Interceptive Care. (A) Patients with advanced caries or advanced periodontal pathology requiring the use of intermediate therapeutic or palliative agents or restorative materials, mechanical debridement, or surgical intervention. (B) Patients who are edentulous or essentially edentulous, or who have no posterior teeth in occlusion, requiring a complete and/or removable partial denture. (C) Patients with moderate or advanced periodontitis requiring non-surgical periodontal treatment (scaling and/or root planing). (D) Patients requiring restoration of essential physiologic relationships. (E) Treatment shall be initiated within 120 calendar days from the date of diagnosis. (F) Patients must have over six months remaining on their sentence within the Department at the time Interceptive Care is initiated and are eligible regardless of their plaque index score. (4) Routine Rehabilitative Care. (A) Patients with an insufficient number of posterior teeth to masticate a regular diet (seven or fewer occluding natural or artificial teeth), requiring a maxillary and/or mandibular partial denture, or with one or more missing anterior teeth resulting in the loss of anterior dental arch integrity, requiring an anterior partial denture. (B) Patients with carious or fractured dentition requiring restoration with definitive restorative materials or transitional crowns. (C) Patients with gingivitis requiring routine prophylaxis or mild periodontitis requiring scaling and root planing. (D) Patients requiring definitive root canal treatment for anterior teeth, which are restorable with available restorative materials. The patient's overall dentition must fit the following conditions: 1. The retention of the tooth is necessary to maintain the integrity of the dentition. 2. The tooth has adequate periodontal support and a good prognosis for long-term retention and restorability. 3. The tooth is restorable using American Dental Association (ADA) and Department approved methods and materials and does not require extensive restoration including either a pin or post retained core build up. 4. There is adequate posterior occlusion, either from natural dentition or a dental prosthesis, to provide protection against traumatic occlusal forces. (E) Patients with non-vital, non-restorable erupted teeth requiring extraction. (F) Treatment shall be initiated within one year from the date of diagnosis. (G) Patients must have at least 12 months remaining on their sentence within the Department at the time Routine Rehabilitative Care is initiated and, with the exception of treatment for periodontal pathology, must maintain an acceptable level of oral hygiene which shall be measured and evaluated by the use of the plaque index score. A plaque index score of 20 percent or less represents an acceptable level of oral hygiene. (5) No dental care needed. Patients not appropriate for inclusion in Emergency, Urgent, Interceptive, Routine Rehabilitative, or Special Dental Needs Care.


(6) Special Dental Needs Care. Patients with special dental needs including patients requiring dental care that is a deviation from treatment policy as well as treatments that may require a contracted specialist or that cannot be accomplished at the institution. (hg) Reception Centers. (1) Newly arriving inmates at a reception center (RC), including new commitments and parole violators, shall receive an initial health screening by a licensed health care provider to identify urgent/emergent dental needs. Within 60 calendar days of a patient's arrival at an Reception Center (RC), a dentist shall perform a dental screening for patients who qualify. Patients who received a dental screening at an RC or a comprehensive dental examination at a mainline facility their endorsed institution within the past six months need not receive a new RC dental screening except as determined by the treating dentist. This includes patients who have paroled and are rearrested as well as those who transfer from one RC to another. (2) Inmates remaining on RC status at an RC for 180 calendar days or longer shall be notified within ten 10 business days after completion of the 180th day that they are eligible to receive an initial comprehensive dental examination performed by a dentist according to the terms described in subsection (ih)(1). (3) Dental treatment provided to RC patients shall be limited to the treatment of Emergency and Urgent Care dental conditions, as defined in subsections (gf)(1) and (gf)(2). Patients who remain on RC status in an RC for 90 calendar days or longer may submit a CDCR 7362 to request Interceptive Care, as defined in subsection (gf)(3), excluding prosthetics. Upon receipt of a CDCR 7362, the dentist shall exercise professional judgment in considering treatment for an Interceptive Care condition for the patient. (ih) Mainline Facility Endorsed Institution. (1) Within ten business days of arrival at a mainline facility their endorsed institution, all patients shall be notified that they are eligible to receive an initial comprehensive dental examination performed by a dentist who shall formulate and document a dental treatment plan. (2) When dental staff becomes aware that a patient has transferred to a mainline facility their endorsed institution, without undergoing an RC dental screening, dental staff at the receiving institution shall schedule the patient for a face-to-face triage encounter to see if the patient has any Emergency or Urgent Care dental conditions, as defined in subsections (gf)(1) and (gf)(2), respectively. Dental staff shall also follow the process regarding comprehensive dental examination eligibility notification outlined in subsection (ih)(1). (3) When a treatment plan is proposed, the patient shall be provided an explanation of its advantages and disadvantages. (4) Each patient's dental health history shall be documented at the time of the initial comprehensive dental examination, signed by the patient, and witnessed by the dentist. Such history shall be available and reviewed at each dental visit. (5) Patients with a plaque index score above 20 percent or who refuse oral hygiene instruction shall receive only Emergency Care, Urgent Care, Interceptive Care, and/or Special Dental Needs Care, as these terms are described in subsections (gf)(1), (gf)(2), (gf)(3), and (gf)(5), respectively. (ji) Re-examination. After the initial comprehensive dental examination, mainline facility patients at their endorsed institution shall be notified that they are eligible to receive a periodic comprehensive dental examination by a dentist as follows: (1) Every two 2 years (biennially), up to the age of 50.


(2) Annually starting at the age of 50 and regardless of age if the patient is diagnosed with diabetes, HIV, or seizure disorder. (kj) Medical Emergencies in the Dental Clinic. The Department shall ensure that emergency medical services are provided in the dental clinic as necessary. (lk) In the provision of dental treatment, Department dentists shall monitor patients with the following conditions and shall adhere to the appropriate protocols. (1) Hypertension. (2) Anticoagulant therapy. (3) Infective endocarditis risk. (4) Prosthetic cardiac valve. (5) Total joint replacement. (6) HIV/AIDS. (7) Bisphosphonate therapy. (8) Diabetes. (9) Pregnancy. (ml) Institution Orientation and Self Care. (1) Mainline facility patients Patients at an endorsed institution shall receive a baseline plaque index score as well as oral hygiene instruction at the time of their comprehensive dental examination and treatment plan formulation. (2) Inmates shall be allowed to brush their teeth at least once a day within the facility's security guidelines and encouraged to brush after meals. (3) Inmates shall be allowed to use dental floss or flossers once a day within the facility's security guidelines. (nm) Periodontal Disease Program. The Department shall maintain a periodontal disease program for the diagnosis and treatment of periodontal disease. Periodontal treatment: (1) Shall be available to patients based on the presence of a comprehensive dental examination with a treatment plan, prior completion of Urgent Care dental treatment as defined in subsection (gf)(2), and regardless of time remaining on their sentence. (2) Shall consist of non-surgical scaling and/or root planing. (on) Dental Restorative Services. The Department shall provide patients with dental restorative services utilizing ADA and Department approved dental restorative materials. Dental restorative services shall be limited to the restoration of carious teeth with enough structural integrity to provide long-term stability. (po) Root Canal Therapy. (1) Endodontics, or root canal therapy, shall only be performed on the upper and lower six anterior teeth for a patient who meets the criteria pursuant to subsection (gf)(4)(D)1.- 4. (2) Posterior root canal therapy may be considered pursuant to section 3352.2(b)3999.365(a) if all the following conditions are met: (A) Conditions listed in subsections (gf)(4)(D)1.- 4. (B) The tooth in question is vital to the patient's chewing ability. (C) The tooth in question is essential as a support tooth for an existing removable cast partial denture or is necessary as a support tooth on a proposed removable cast partial denture for that arch. (D) Treatment must be approved by the Dental Authorization Review (DAR) Committee and the Dental Program Health Care Review Committee prior to initiating the procedure.


(3) Root canal therapy shall not be performed when extraction of the tooth is appropriate due to non-restorability, periodontal involvement, or when the tooth can easily be replaced by an addition to an existing or proposed prosthesis in the same arch. (qp) Oral Surgery. A full range of necessary oral surgery procedures including biopsies shall be available to patients regardless of time remaining on their sentence. Any clinicallymedically necessary oral surgery procedure, as determined by health care staff, that cannot be accomplished at the local institution shall be made available by referring the patient to contracted oral surgeons, or to outside facilities. (rq) Dental Prosthodontics. (1) When a patient's treatment plan includes a dental prosthesis, the treating dentist shall inform the patient that the prosthesis may not be completed prior to the patient's parole date. (2) A dental prosthesis shall be constructed only when: (A) The dentist believes the patient can tolerate it and can be expected to use it on a regular basis. (B) A patient is edentulous, is missing an anterior tooth, or has seven or fewer upper and lower posterior teeth in occlusion. (C) All diagnosed preventive, restorative, endodontic, and oral surgery procedures have been completed. (D) The active therapy phase of periodontal therapy has been completed and the patient is free of periodontal disease or is in periodontal maintenance. (E) Clinically adequate and diagnostic radiographs are present in the health record prior to initiating dental prosthodontic services. (F) The patient has an Interceptive Care prosthetic need (e.g., complete denture) and is eligible pursuant to subsection (gf)(3); or the patient has a Routine Rehabilitative Care prosthetic need (e.g., partial denture) pursuant to subsection (gf)(4). Time requirements are calculated from the date final impressions are taken. (3) All dental prostheses which are fabricated for patients shall have the patient's last name and CDCR number embedded into the prosthesis for identification purposes. (sr) Removal of orthodontic bands/brackets and/or arch wires shall be at the discretion of the treating dentist and does not require approval by the DAR Committee. (ts) Within the second trimester of gestation and regardless of their plaque index score, pregnant patients shall receive a comprehensive dental examination, periodontal examination, oral hygiene instruction, and the necessary periodontal treatment in order to maintain periodontal health during the gestation period. (ut) The Department shall utilize a dental hold process when the transfer or transport of a patient is not clinically appropriate. The treating dentist in conjunction with the Supervising Dentist (SD) shall determine if a dental hold should be placed on a patient. When a dental hold has been placed and the patient refuses treatment of the condition that prompted placement of the hold, the SD or treating dentist shall remove the hold and document the incident. A dental hold shall be removed or lifted only by the treating dentist or SD. (vu) Nourishments and supplements may be prescribed for patients who are pregnant, diabetic, immunocompromised, malnourished, or those with dental or oropharyngeal conditions causing difficulty eating regular diets. (wv) Restraints. If a patient requiring dental treatment also requires use of restraint gear, such restraints shall be selected to enable sitting in a dental chair and shall remain in place during the treatment. Exceptions require concurrence of the treating dentist, the escorting officer, and a


lieutenant. For pregnant patients, the rules provided in sections 3268.2(b), (d), and (e) concerning the use of restraints shall be followed. Note: Authority cited: Section 5058, Penal Code. Reference: Sections 3424 and 5054, Penal Code; and Perez, et al. v. Cate, et al., USDC no. 3:05-cv-05241-JSW (No. Cal.)(No. C05-05241 JSW), U.S. District Court, Northern District of California.

California Department of Corrections and Rehabilitation California Correctional Health Care Services

Initial Statement of Reasons NCHCR 20-03 April 14, 2020 1

INITIAL STATEMENT OF REASONS The California Department of Corrections and Rehabilitation (CDCR) proposes to amend sections 3341.3, 3341.5, 3377.1, 3999.98, 3999.99, 3999.364, 3999.365, and 3999.367 of the California Code of Regulations (CCR), Title 15, Division 3, regarding health care definitions. Summary of the Proposal Problem Statement: In January 2019, the Department revised the definition of the term “medically necessary” in Title 15, section 3999.98, establishing this term as the interdisciplinary standard for the provision of health care services. Regulations currently using the term “clinically necessary” must be updated to the term “medically necessary” to conform to current usage as this term now functions as the single interdisciplinary standard for the provision of health care services to CDCR patients. Objective: This regulatory action replaces the term “clinically necessary” with the term “medically necessary” and relocates or deletes several definitions as necessary for consistency.

Benefit: The proposed regulations will:

• Provide a consistent treatment standard for the delivery of health care services within CDCR institutions.

• Reorganize and integrate various definitions for clarity of reference for patients and staff.

ECONOMIC IMPACT ASSESSMENT In accordance with Government Code (GC) section 11346.3(b), the Department has made the following assessments regarding the proposed regulation:

1. Creation or Elimination of Jobs within the State of California

The Department does not expect that the proposed regulations will have an impact on the creation of new or the elimination of existing jobs within the State of California. The proposed regulations clarify definitions and standards which only affect patients within CDCR.

2. Creation of New or Elimination of Existing Businesses within the State of California

The Department does not expect that the proposed regulations will have an impact on the creation of new or the elimination of existing businesses within the State of California. The proposed regulations clarify definitions and standards which only affect patients within CDCR.


2 Initial Statement of Reasons NCHCR 20-03 April 14, 2020

3. Expansion of Businesses Currently Doing Business within the State of California

The Department does not expect that the proposed regulations will have an impact on the expansion of businesses currently doing business within the State of California. The proposed regulations clarify definitions and standards which only affect patients within CDCR.

4. Benefits of the Regulation to the Health and Welfare of California Residents, Worker Safety, and the State’s Environment

The proposed regulatory action will amend, reorganize, and clarify definitions and standards regarding the provision of health care to patients within CDCR. The proposed changes will benefit the health and welfare of CDCR patients, staff, and the general public by improving the organization and coherence of health care definitions, and will ensure a consistent treatment standard for the delivery of health care services to CDCR patients.

Statement of Determinations Reasonable Alternatives In accordance with GC section 11346.5(a)(13), the Department has determined that no reasonable alternative considered or that has otherwise been identified and brought to the attention of the Department would be more effective in carrying out the purpose for which this action is proposed, would be as effective and less burdensome to affected private persons than the proposed action, or would be more cost effective to affected private persons and equally effective in implementing the statutory policy or other provisions of law. Local Mandates The Department has determined that this action imposes no mandates on local agencies or school districts, or a mandate which requires reimbursement pursuant to GC sections 17500 - 17630.

Significant Adverse Economic Impact The Department has made an initial determination that the proposed regulations will not have a significant statewide adverse economic impact directly affecting business, including the ability of California businesses to compete with businesses in other states because this regulatory action relates strictly to definitions and standards pertaining to the provision of health care services to patients in CDCR institutions. Based on the economic impact assessment, the Department has determined that the regulation will not significantly affect the following:

1. The creation or elimination of jobs within the State of California.



2. The creation of new businesses or the elimination of existing businesses within the State of California.

3. The expansion of businesses currently doing business within the State of California. The economic impact assessment shows that the proposed regulatory action will benefit the health and welfare of California residents, worker safety, and/or the State’s environment. Reports, Studies and Documents Relied Upon The Department has not identified nor has it relied upon any technical, theoretical, or empirical study, report, or similar document.

SPECIFIC PURPOSE AND RATIONALE FOR EACH REGULATION PROPOSED FOR AMENDMENT, ADOPTION, OR REPEAL Non-substantive renumbering, organization, grammar, and punctuation changes are made throughout the following regulatory sections for accuracy and readability. Chapter 1. Rules and Regulations of Adult Operations and Programs Subchapter 4. General Institution Regulations Article 7. Segregated Housing 3341.3. Security Housing Unit. Section 3341.3(d) is amended to replace the word “clinically” with “medically” before the word “necessary.” This is necessary to ensure consistency and clarity because the term “clinically necessary” is no longer used. The term “medically necessary” provides the interdisciplinary and consistent treatment standard for the Department.

3341.5. Suspending Security Housing Unit Terms. Sections 3341.5(a)(1) and (b)(1) are amended to replace the word “clinically” with “medically” before the word “necessary.” This is necessary to ensure consistency and clarity because the term “clinically necessary” is no longer used. The term “medically necessary” provides the interdisciplinary and consistent treatment standard for the Department. Article 10. Classification 3377.1. Inmate Custody Designations. Sections 3377.1(d)(1)(A) and (d)(1)(B) are amended to replace the word “clinically” with “medically” before the word “necessary.” This is necessary to ensure consistency and clarity because the term “clinically necessary” is no longer used. The term “medically necessary” provides the interdisciplinary and consistent treatment standard for the Department.



Chapter 2. Rules and Regulations of Health Care Services Article 1. Health Care Definitions Existing section 3999.98 is amended to add the following definition: “Health Record(s)” is relocated from section 3999.364, Dental Definitions, to section 3999.98, Definitions. This is necessary because this definition is applicable to all of Chapter 2 and is not limited to the Dental Care article. In addition, the last sentence, “Health care records shall be maintained in a manner that supports continuity of care” is deleted as it is a directive, which is now covered in section 3999.216(b). “Medically Necessary” is amended to add the sentence, “This standard does not confer any additional rights or benefits not currently covered under Medicare.” This is necessary to ensure that services, medical equipment, and medications deemed “medically necessary” under Medicare, which may not explicitly fall under the definition for “medically necessary” in section 3999.98, may still be provided within the CDCR health care delivery system.

Chapter 2. Rules and Regulations of Health Care Services Subchapter 3. Health Care Operations Article 6. Dental Definitions Section 3999.364 is amended as follows: The definition for the term “Clinically Necessary” is deleted. This is necessary to ensure consistency and clarity because the term “clinically necessary” is no longer used. The term “medically necessary” provides the interdisciplinary and consistent treatment standard for the Department. The definition for the term “Health Record(s)” is deleted from this section and relocated to section 3999.98. This is necessary because this definition is applicable to all of Chapter 2 and is not limited to the Dental Care article and the final sentence is now covered in section 3999.216. The definition for the term “Patient” is deleted from this section. This is necessary to remove duplication because the definition is already located in section 3999.98. The terms “Dental Priority Classification,” “Face-to-Face Triage Encounter,” “Limited Problem Focused Exam Encounter,” “Plaque Index Score,” and “Root Canal Therapy” are relocated from section 3999.367 to section 3999.364 to consolidate definitions specific to dental care in one location. This is necessary for consistency of reference in the text.

3999.365. Dental Authorization Review Committee.



Section 3999.365(a)(1) is amended to add the phrase “pursuant to section 3999.200(b).” This is necessary to ensure clarity by providing patients and staff with the proper section reference covering excluded dental services. Sections 3999.365(a)(3) and (a)(4) are amended to replace the word “clinically” with “medically” before the word “necessary.” This is necessary to ensure consistency and clarity because the term “clinically necessary” is no longer used. The term “medically necessary” provides the interdisciplinary and consistent treatment standard for the Department. In addition, the qualifying phrase “as determined by health care staff” is deleted. This is necessary because the individuals qualified to make a determination of medical necessity are set forth in the definition for “medically necessary” in section 3999.98. Section 3999.365(c) is amended to delete the “/or.” This is necessary for clarity as both the DAR Committee and the Dental Program Health Care Review Committee approval process may be bypassed if the Supervising Dentist determines the specialty services are required for an Emergency dental condition or an Urgent dental condition. In addition, references to sections 3355.1(g)(1) and (g)(2) are deleted and renumbered to 3999.367(f)(1) and (f)(2). This is necessary to account for the renumbering of section 3355.1 to 3999.367 and the deletion of section 3999.367(a).

3999.367. Dental Care. Section 3999.367(a) is deleted because there is no longer a need for an introductory statement in this section. This is necessary as the definitions in this section are being deleted or relocated to section 3999.364 to consolidate definitions specific to dental care in one location and to provide consistency and clarity. Sections 3999.367(a)(1) – (a)(3) are deleted and relocated to section 3999.364. This is necessary to consolidate definitions specific to dental care in one location and to provide consistency and clarity. Section 3999.367(a)(4) is deleted because the term “mainline facility” is no longer used and has been replaced with the preferred term “endorsed institution.” This is necessary for consistency and to conform to current usage. Section 3999.367(a)(5) and (a)(6) are deleted and relocated to section 3999.364. This is necessary to consolidate definitions specific to dental care in one location and to provide consistency and clarity. Section 3999.367(b)(1)(A) is renumbered as (a)(1)(A) and amended to account for the deletion of sections 3999.367(a)-(a)(6) and to add the name of the form, “Health Care Services Request Form,” after the form number “CDCR 7362.” This is necessary to ensure consistency and clarity because it is now the first time the CDCR 7362 is mentioned in section 3999.367, given the relocation of the former section (a)(2).



Section 3999.367(b)(4) is renumbered as (a)(4) and amended to add the word “encounter” after “limited problem focused exam.” This is necessary to ensure consistency and clarity because the proper term is defined in section 3999.364 as “Limited Problem Focused Exam Encounter.” Section 3999.367(g) is renumbered as (f) and amended to replace the phrase “a Mainline Facility” with the preferred phrase “their endorsed institution.” This is necessary for consistency and to conform to current usage. In addition, the word “clinical” before “necessity” is replaced with the word “medical.” This is necessary to ensure consistency and clarity because the term “clinical necessity” is no longer used. The term “medical necessity” provides the interdisciplinary and consistent treatment standard for the Department. Section 3999.367(g)(3)(B) is renumbered as (f)(3)(B) and amended to delete “and/.” This is necessary for clarity as dentures are either complete or partial. Section 3999.367(g)(3)(C) is renumbered as (f)(3)(C) and amended to delete “/or.” This is necessary for clarity as “scaling and root planing” is standard terminology used for the non-surgical periodontal treatment provided for patients with moderate or advanced periodontitis.

Section 3999.367(g)(4)(A) is renumbered as (f)(4)(A) and amended to delete “and/.” This is necessary for clarity as either a maxillary or mandibular partial denture is acceptable. Section 3999.367(h)(1) is renumbered as (g)(1) and amended to delete the first sentence, “Newly arriving inmates at a reception center (RC), including new commitments and parole violators, shall receive an initial health screening by a licensed health care provider to identify urgent/emergent dental needs.” This is necessary because the initial health screening at Reception Centers is provided by licensed nursing staff pursuant to the definition of Reception Center Initial Health Screening and Triage in section 3999.98 and the process for identifying health care needs of patients at Reception Centers is outlined in section 3999.305, Reception Center Health Care. In addition, the phrase “a mainline facility” is replaced with the preferred phrase “their endorsed institution.” This is necessary for consistency and to conform to current usage. Section 3999.367(h)(2) is renumbered as (g)(2) and amended to replace the word “ten” with the number “10.” This is necessary for consistency.

Section 3999.367(i) is renumbered as (h) and amended to replace the term “Mainline Facility” with the preferred term “Endorsed Institution.” This is necessary for consistency and to conform to current usage. Sections 3999.367(i)(1) and (i)(2) are renumbered as (h)(1) and (h)(2) and amended to replace the phrase “a mainline facility” with the preferred phrase “their endorsed institution.” This is necessary for consistency and to conform to current usage. Section 3999.367(i)(5) is renumbered as (h)(5) and amended to delete “/or.” This is necessary for clarity as patients with a plaque index score above 20 or those who refuse oral hygiene instruction shall have access to each of the following: Emergency Care, Urgent Care, Interceptive Care, and Special Dental Needs Care.



Section 3999.367(j) is renumbered as (i) and amended to delete the term “mainline institution” and add the preferred phrase “at their endorsed institution” after the word “patients.” This is necessary for consistency and to conform to current usage. Section 3999.367(j)(1) is renumbered as (i)(1) and amended to replace the word “two” with the number “2.” This is necessary for consistency. Section 3999.367(m)(1) is renumbered as (l)(1) and amended to replace the phrase “Mainline facility patients” with the preferred phrase “Patients at an endorsed institution.” This is necessary for consistency and to conform to current usage. Section 3999.367(n)(2) is renumbered as (m)(2) and amended to delete “/or.” This is necessary for clarity as “scaling and root planing” is the standard terminology used for non-surgical periodontal treatment provided in the Periodontal Disease Program.

Section 3999.367(p)(2) is renumbered as (o)(2) and amended to delete reference to section 3352.2(b) and renumber it as section 3999.365(a). This is necessary to account for the renumbering of section 3352.2(b). Section 3999.367(q) is renumbered as (p) and amended to replace the word “clinically” with “medically” before the word “necessary.” This is necessary to ensure consistency and clarity because the term “clinically necessary” is no longer used. The term “medically necessary” provides the interdisciplinary and consistent treatment standard for the Department. In addition, the qualifying phrase “as determined by health care staff” is deleted. This is necessary because the individuals qualified to make a determination of medical necessity are set forth in the definition for “medically necessary” in section 3999.98. Section 3999.367(s) is renumbered as (r) and amended to delete “and/.” This is necessary for clarity as either orthodontic bands/brackets or arch wires may be removed at the discretion of the treating dentist.